M
Mary Anne PA
SEXUAL FUNCTION AFTER RADICAL PROSTATECTOMY
Radical prostatectomy is performed with increasing frequency as the most common treatment for prostate cancer. Prostate cancer is the commonest cancer in men and is often diagnosed in men in their 50’s and 60’s otherwise in the “prime of life.” As surgical techniques and expertise have improved, the incidence of side-effects has lessened substantially; unfortunately serious effects on a man’s sexual function, particularly his ability to get an erection remains an almost universal problem.
In radical prostatectomy the prostate gland along with the seminal vesicles and a length of urethra are removed. Nerves supplying the erectile “message” pass closely around the prostate gland like a spider’s web and are often damaged even when nerve-sparing techniques are used. As a result, a man will normally lose the capacity to have erections immediately after the operation, however with time, there is usually some return of erections. In part, the return of erections depends on the extent to which the nerves which lie close to the prostate could be spared during surgery. To use nerve-sparing surgery or not is a choice that the surgeon is only able to make at the time of surgery, since to spare the nerves and also leave cancer behind would defeat the purpose of the operation.
After a radical prostatectomy, 20-50% of men have a return of erections with improvement reported for up to 4 years postoperatively. There is emerging evidence that the early use of medication to allow erections to occur can improve the chances of the return of normal erectile function. The use of radiotherapy may further damage the nerves and blood vessels and such damage can get worse over a number of years as the tissues scar. Hormone therapy will cause a sudden drop in testosterone giving the man an artificial “male menopause.” This will profoundly affect a man’s interest in sex as well as making the penis less responsive.
After a radical prostatectomy, the penis may not be as responsive to visual stimulation; more direct stimulation of the penis is often helpful. It is possible to have vaginal intercourse with a partial erection, vaginal stimulation may encourage further and better quality erections. Some people find the erection is stronger when standing up.
Because the majority of ejaculatory fluid is made by the prostate and seminal vesicles, and also that the valve effect of the gland is lost a man will not ejaculate after radical prostatectomy; he can however reach orgasm, even without an erection. Such an orgasm is “dry” but just as pleasurable and less messy!
Some men notice a foreshortening of the penis reflecting the length of “pipe-work” removed.
TREATMENT:
First line treatment for erectile dysfunction is now generally accepted to be the new oral drugs Viagra, Cialis and Levitra. These drugs work within the tissues of the penis amplifying the sexual chemicals and the erectile process. Unfortunately as the “message” is not getting through after radical prostatectomy they are not particularly helpful until partial erections are happening. Whilst there is minimal erection the mainstay of treatment remains penile injection treatment where a synthetic copy of the chemical messenger is injected directly into the penis.
Injections can start almost as soon as the catheter is removed, indeed it seems that less discomfort is felt the earlier treatment commences. Injection of alprostadil with or without phentolamine results in an erection lasting about an hour. The commonest side effect is penile pain which tends to be a problem only with the first few injections. The treatment is less expensive than tablets usually costing $5-10 per dose as opposed to $15-20 for tablets. Self injection is surprisingly easy and most patients get over there understandable misgivings very quickly. As soon as the patients own erections begin to return many men choose to change over to oral treatment but it is safe to injections in the long term.
For those unable to tolerate injection therapy and unresponsive to tablets vacuum erection devices remain a useful option. A canister is placed over the penis and the erection develops as a vacuum is produced by a manual or electric pump. The erection is held by a tight rubber ring until intercourse is completed.
If there has been no return in erectile function after 2-3 years many men consider the permanent solution of penile implant surgery. This requires further surgery to replace the erectile apparatus with an artificial device which is inflated and deflated by a discreet pump situated in the penis.